NIDA Director Dr. Nora Volkow answers some questions on the Monitoring the Future Survey

On December 14 (last week), the US National Institute on Drug Abuse (NIDA) released the findings on adolescent drug use and trends as determined from the 35th annual Monitoring the Future (MTF) survey (press release). The ambitious survey is conducted with NIDA funding* by the University of Michigan's Institute for Social Sciences led currently by Dr. Lloyd Johnston. The larger survey began in 1975 with only high-school seniors and was expanded in 1991 to include 8th and 10th graders to improve the ability to measure changes as a population progresses through school. A very detailed white paper on the MTF methodology is available as a PDF from the University of Michigan.

This year's survey included 46,348 students from 386 public and private schools in the United States. The good news is that methamphetamine use and cigarette smoking rates are decreasing in adolescents, although smokeless tobacco use is increasing. Cocaine and hallucinogen use have also declined but previous declines in marijuana use have stabilized. Perhaps the biggest concern is that the use of prescription drugs, opioids in particular, has increased sharply. Prescription drug abuse is increasing in adults but even I'm surprised that kids are getting into the act as well.

Backstory - the part where the blogger says things you wouldn't see in formal journalism
Although I'm not a substance abuse researcher, I have taught in the area to pharmacy and medical students since 1992 and many drugs of abuse are themselves naturally-occurring plant or fungal products. But I wouldn't say that this blog is on the NIDA radar, so let me share with you this backstory as to why we have this post today:

I've got to hand it to NIDA for their public outreach and responsiveness. They contracted with Ogilvy Public Relations Worldwide and we were approached by their senior account executive, Chris Heydt, for our interest in participating in a live chat session the on the 15th with NIDA Director, Dr. Nora Volkow. If you don't know much about Dr. Volkow and the remarkable person and scientist that she is, you must read this 2006 story by Bill Snyder in Lens, a Vanderbilt Medical Center publication. Her work was also recognized last week by Inserm, the French analog of the NIH:

Each year, it honors researchers for their contributions to basic and clinical research that enhance public health. Dr. Volkow's selection acknowledges her innovative imaging research showing drug addiction to be a disease of the brain that usurps the reward circuitry and leads to compulsive behaviors.

Unfortunately, the chat had to be canceled at the last moment, understandably given the competing press interest following the annually anticipated release of the survey results. However, Chris got back to me with apologies and said that Dr. Volkow would respond via e-mail to any questions I had prepared and, lo and behold, I received the following answers yesterday via her staff assistant, Susan Schlossberg.

What I like about NIDA is that they contracted with Ogilvy, a PR firm with a history of respectful cultivation of bloggers as detailed by their 2007 code of ethics in approaching bloggers.

So, I have to say that NIDA gets it. And I'm also impressed by the professionalism at Ogilvy.

But, now to the questions I had for Dr. Volkow. I was primarily interested in cultural influences on drug use in adolescents, particularly with regard to substance choice. Most of my 12th grade year's drug abuse was comprised of sitting in my buddy Tommy's Firebird in the Sumner Ave. parking lot of Seaside Heights, New Jersey, drinking warm Budweiser in the soft summer rain (because that's what Bruce Springsteen wrote about in Jungleland.) So, I kicked off my three questions with a reflection on a trend which claimed Pimp C two years ago.

Terra Sig: The hip-hop music community out of Houston popularized the consumption of "purple drank" or "sippin' syrup," usually sourced from an opioid-containing cough syrup, sometimes also containing promethazine. How much do you people this cultural phenomenon may have contributed to an uptick in Rx opioid use in young people?

Dr. Nora Volkow: Interesting question, and unfortunately one for which we do not have much research. The use of these syrups is thought to have emerged first in Pensacola, Fla., around 1999 as a social drink among drug dealers, and apparently gained broader popular attention a year later, when the group "Three 6 Mafia" released a single called "Sippin' on Some Syrup." As far as the effects of "popularizing" opioid cough syrups on young people is concerned, we don't really know. It's especially hard to pinpoint any one factor that is responsible for trends we see over many years. And we know, for example, that availability of opioid medications has increased (in terms of numbers of prescriptions), which can also contribute to its potential abuse.

The abuse of prescription opioids is at alarmingly high levels (1 in 10 seniors reporting past year non-medical use of Vicodin; 1 in 20 for OxyContin), however, our Monitoring the Future (MTF) Survey of drug use has actually not shown increases in abuse since 2002. While trendlines for annual use of narcotics other than Heroin did jump in the year 2002 from 6.7% to 9.4% of seniors that discontinuity in the data can be easily explained by the fact that, beginning in 2002, a revised set of questions on other narcotics use was introduced in which Talwin, laudanum, and paregoric were replaced with Vicodin, OxyContin, and Percocet.

Now, going back to the cough syrup issue, we have limited research on its pattern of abuse in different populations. MTF began asking about abuse of over-the-counter cough syrups (containing dextromethorphan or DXM) in 2007; in 2008, 5.9% of 12th graders reported abusing cough syrup to get high. It is worth noting, though that in 2004, a University of Texas survey (1) found that 8.3% of Texas secondary school students reported having taken enough codeine syrup to get high. The findings of this survey are sobering, for example, a majority of college students believed that their friends felt codeine and promethazine use was "normal" and "cool" among students their age, and that reinforcing factors, such as peer pressure and curiosity, contributed to initial use of codeine and promethazine cough syrup.

Unfortunately, there is a lingering and hard to dispel misperception that medications (whether they are prescribed or over the counter) are always safe. But the danger stems from the fact that too much of the opiate codeine can depress the central nervous system and cause heart and lung failure and overdosing on prescription syrup can be fatal. Unfortunately, because of a lack of precise data, we don't really know how many people have died directly as a result of this dangerous behavior. It is certainly conceivable that some abusers of codeine containing cough syrup may have become addicted to opiates and moved to abusing prescription opiate analgesics and/or other opium-derived products available on the black market. Unfortunately, we do not have data that shed light on the magnitude of this progression.

(1) Peters et al. Beliefs and social norms about codeine and promethazine hydrochloride cough syrup (CPHCS) use and addiction among multi-ethnic college students. J Psychoactive Drugs. 2007 Sep; 39(3):277-82.

AP/TS Comments: Well, Dr. Volkow schooled me on the origin of sippin' syrup: Pensacola, not Houston as I imagined. One of the difficulties, as she noted, is that the survey is not designed to determine the influences on the use trends. But opioid abuse is particularly concerning for two reasons: 1) it's pretty easy to overdose on opioids and the tendency is not to count the volume of syrup consumed the way one might with pills or alcoholic beverages and 2) the risk of physical dependence is very high among all drugs of abuse. The sense that a prescription drug might seem "safer" than a street substance is not something that comes immediately to me but certainly might be food for thought in talking with young people about drug use.

Terra Sig: I am very pleased to see methamphetamine use decline, perhaps due to more stringent regulation of pseudoephedrine and ephedrine. However, how do you view some of the very aggressive and graphic ad campaigns such as the Colorado Meth Project in targeting meth use among adolescents? More broadly, are our youth-oriented ad campaigns really working?

Volkow: The scientific evidence to date is not convincing that the State methamphetamine health campaigns (Montana or Colorado) have led to the specific declines observed. There are many other potential explanations, including law & DEA efforts, drug availability, cost, strict regulation of pseudoephedrine, and secular drug trends. This is not to say that ad campaigns generally are ineffective. One youth-oriented ad campaign that has been a success is the American Legacy Foundation's campaign against tobacco. Their approach was to appeal to youth on their own terms--in this case, rebelling against authority, that being the tobacco industry.

There are also science-based prevention programs that have been shown to decrease methamphetamine use in youth; and there are research projects studying how ad campaigns can be made more effective. One focuses on targeting youth with certain characteristics (e.g., sensation seeking), and has shown effectiveness against illicit drug use; others are determining what messages work best. In general, the data suggest that scare tactics are not usually effective, particularly if they are not credible. Focusing on rare outcomes, or very downstream ones that are counter to what youth observe in others who use drugs (or what they see on You Tube) can be less effective. In some cases an indirect approach may be better, especially among youth who are already using.

AP/TS Comments: The ad campaign I was referring to in Colorado is one that I have been following for the last year or so. I had previously held the stereotypical perception that methamphetamine use was greatest among salt-of-the-earth, rural Midwesterners until I learned that 41% of Colorado meth addicts began using at age 17 or earlier. Here's one of their ads:

Pretty shocking. It certainly gets my attention. Here are some other print ads and television ad clips.

But after these ads were first released, the blog for Denver-Boulder independent weekly, Westword, had a contest for fake anti-meth slogans to play on the "Meth Will Change That" tagline. The ads essentially became parodies and I haven't been able to learn much since about their effectiveness. So I think that Dr. Volkow's point on scare tactics are spot on as well as the reason for the efficacy of the American Legacy Foundation's anti-tobacco campaign in tuning in to the adolescent, anti-authority vibe.

Terra Sig: Was there any assessment as to the contribution of highly-caffeinated energy drinks in reducing the use of stimulants among youth? My anecdotal observations have been that energy drinks are broadly used and abused by youngsters and young adults, particularly of the "hipster" demographic. Might we be trading off cocaine and amphetamine for high doses of caffeine?

Volkow: Again, your question is one for which we don't have any data to answer it. The intense marketing of high caffeine content beverages, particularly to younger and younger audiences is something that requires attention to evaluate if there are untoward effects including its facilitating the use of other drugs. Caffeine is an atypical stimulant; its pharmacological profile and behavioral effects are quite different from typical stimulants like methylphenidate, amphetamine, or cocaine. Critically, caffeine is not a powerful dopaminergic booster in the nucleus accumbens, the core of the brain's reward system, which is responsible for the euphoria that can be elicited upon abusing typical stimulants. In summary, although high caffeine intake could have some adverse behavioral impacts of its own, and possibly on general abuse patterns, I think it is unlikely that it will trigger a "trade off" from stimulant drugs.

AP/TS Comments: I was curious about this in light of a symposium NIDA held in July 2009 in conjunction with the NIH Office of Dietary Supplements. Among the concerns considered at this conference was the use of caffeinated alcoholic beverages - an excellent presentation with notes by Mary Beth O'Brien, MD, of Wake Forest University Medical Center is posted here (PPT, 3.4MB). The problem with these, of course, are that the added caffeine makes one feel less-impaired than with a similar amount of non-caffeinated alcoholic beverage while one's blood alcohol content is exactly the same.

But, yes, caffeine is nowhere as addictive as cocaine although abrupt abstinence does produce a withdrawal syndrome. Still, when I see students chugging 40 oz. cans of MegaJugularPowerShooter, I have to think that might be better than becoming addicted to cocaine.

If you have any thoughts on these discussion topics, or any other aspect of the Monitoring the Future survey results, feel free to leave a comment.

Once again, many thanks to Dr. Volkow, the good people at NIDA, and Chris Heydt at Ogilvy PR for making this happen.

Dr. Nora Volkow (above left) being interviewed last month at Brookhaven National Laboratory by an obscure CBS News personality for an upcoming 60 Minutes segment on "smart drugs" such as modafinil (Provigil®).

Footnotes:

*For those who know NIH nomenclature, the grant number is 5R01DA001411-35, reflects how long ago the original grant was awarded - not the 35 as much as the "1411."